Article Title: A values-based approach to medical leadershipAuthors: Charlotte Moen and Patricia Prescott

Name of Institution: Edge Hill University

Contact details: Edge Hill University, Faculty of Health & Social Care, Post Graduate

Medical Institute/Post Graduate Professional Education, St Helens Road, Ormskirk,

Lancashire, L39 4QP Telephone: 01695657028 Email: moenc@edgehill.ac.uk

Corresponding author: Charlotte Moen – contact details above.

Wordage: 2,468 including abstract, key points/words and excluding tables/figures and

Reference List.

Ms Charlotte Moen is Programme Lead in the Post Graduate Medical Institute/Post Graduate

Professional Education, Faculty of Health & Social Care, Edge Hill University, Ormskirk,

Lancashire L39 4QP

Ms Patricia Prescott is Senior Lecturer at Edge Hill University, Faculty of Health & Social

Care, Post Graduate Professional Education, Ormskirk, Lancashire

Correspondence to:Ms C Moen (moenc@edgehill.ac.uk)

A values-based approach to medical leadership

Abstract

Within the UK health and care services, several high profile inquiries have

recommended a new style of leadership aligned with the National Health Service

values. The style of leadership required is a values-based, authentic approach. This

paper reviews Dr Stephen R. Covey’s (1989) principle-centred leadership model and

aims to explore whether the 7 Habits of Highly Effective People® can be applied to

medical practice. Furthermore the relationship between Covey’s 7 Habits®, the

leadership and management standards for medical professionals and key driving

leadership policies are examined, with an emphasis on how to restore the character ethic

through a values-based approach to medical leadership. We explore how an applied

version of Covey’s model has been embedded within a medical education context. We

conclude the applied model offers a structured, reflective and practical approach to

demonstrating leadership authenticity and trust thereby facilitating a

values-based/principle-centred leadership approach.

Key terms: leadership, principle-centred, values-based, medical leadership, authentic leadership

Short Introduction

Integrity, trust and authenticity are essential characteristics of an effective leader.

These characteristics are demonstrated through a values-based approach to

leadership. This article explores whether Covey’s (1989) Principle-Centred

leadership model is a useful approach to developing doctors’ leadership qualities

and skills.

Introduction

Many European countries are reconstructing their healthcare systems to improve

efficiency, reduce cost and improve the quality of care. In the UK the National Health

Service (NHS) is at a ‘critical leadership tipping point’ (Rose, 2015:45]. Whilst it is

recognised there is a need to deliver services with smaller budgets, there is also a need

to respond to the quality recommendations from the Francis (Francis, 2013), Keogh

(NHS England, 2013) and Berwick (National Advisory Group on the Safety of Patients

in England, 2013) reports. The additional challenges include, the NHS is operating with

unprecedented levels of demand, low employee morale, increasing patient complexity

and life expectancy. Thus the key goal is to do more with less, often referred to as the

Nicholson challenge (Appleby et al, 2014) and at the same time, increase quality and

employee engagement (The King’s Fund, 2015).

In response to the challenges outlined above, the NHS Chief Executive, Simon Stevens,

published his five year vision for the NHS (NHS England, 2014). In addition, Lord Rose

was commissioned by the Secretary of State for Health to review how best to develop

leaders to deliver the 5 Year Forward View (Rose, 2015). His recommendations

include the need to ‘develop, recognise and reward appropriately, leadership qualities

across the whole NHS workforce’ and the recognition that ‘strong leadership and

management’ are required at all levels of the organisation (Rose, 2015: 6).

Within the Francis Report (2013) it was acknowledged there was a lack of leadership

based on values throughout the NHS. Post Francis there has been a strong emphasis on

clinical leadership at every level of an organisation because it is argued that clinical

leadership is essential to promoting high quality patient care through driving up

standards, improving patient safety and enhancing patient experience (The Kings Fund,

2013; Department of Health, 2013a). Post Francis there has also been a call for a

different leadership approach with a focus on integrity and for leaders ‘to be seen as

embodying the culture and values of the NHS’ (Rose, 2015: 45). One could argue this

signals a return to the character ethic whereby leaders reinforce the values of high-

quality care.

A new approach to leadership

In addition there has been a move away from a heroic leadership style that focussed on

one formal leader at the top of an organisation to a shared approach (Academy of

Medical Royal Colleges and NHS Institution for Innovation and improvement, 2010;

West et al, 2014). This resonates with Steven’s 5 Year Forward Plan (NHS England,

2014) as Steven’s argues in order to improve patient safety, experience and quality, a

radically different style is required, based on collective including system leadership

approaches. The underpinning philosophy is that leadership is not restricted to people

who hold designated leadership roles; instead leadership is shown through a shared

sense of responsibility for the success of the organisation and its services (Academy of

Medical Royal Colleges and NHS Institution for Innovation and Improvement, 2010;

West et al, 2014). Such an engaged leadership approach facilitates increased

effectiveness without reducing employee motivation or well-being (West et al, 2014).

The personal qualities and core values that are central to engagement are acting with

integrity, being honest and consistent as well as compassion, dignity, respect and

equality (Faculty of Medical Leadership and Management, 2015).

Doctors’ leadership role

Within the medical context, leadership is a key part of doctors’ professional work

regardless of specialty and setting. It is already a requirement of all doctors as laid out

in both the General Medical Council’s (GMC) publication Promoting Excellence:

standards for medical education and training (GMC, 2016) and Leadership and

Management for Doctors (GMC, 2012). The competencies to meet these requirements

are articulated within the Medical Leadership Competency Framework (MLCF)

(Academy of Medical Royal Colleges and NHS Institution for Innovation and

improvement, 2010). The first domain within the MLCF is Demonstrating Personal

Qualities; specifically doctors need to demonstrate effective leadership to draw upon

their values, strengths and abilities to deliver high standards of care. This requires

doctors to demonstrate competence in the areas of: Developing Self Awareness,

Managing Yourself, Continuing Personal Development and Acting with Integrity.

Within the element of self-awareness doctors need to be aware of their own principles

and values and within the element of integrity doctors need to behave in an open, honest

and ethical manner. This implies an inside-out approach is required, based on a strong

character ethic.

Leadership and Management Standards for doctors

More recently the Faculty of Medical Leadership and Management (FMLM) have

published the Leadership and Management Standards for Medical Professionals

(FMLM, 2015). The professional standards define what is expected of doctors working

in the UK health sector, to lead, manage and improve healthcare delivery and health

outcomes. The FMLM argue an ‘effective medical leader is defined by how and what

they do, underpinned by why they do it’ (FMLM, 2015:2). The underpinning ‘why’ is

guided by the seven Principles of Public Life (The Committee on Standards in Public

Life, 1995) and the General Medical Council’s Good Medical Practice (2013). It is

interesting to note, these 7 principles and the GMC guidance correlate with the

underpinning principles of Dr Stephen R. Covey’s 7 Habits of Highly Effective

People® (Table 1). The ‘how’ and ‘what’ medical leaders do is articulated as three

clusters of behaviours that can be observed, measured and developed. These three

clusters are:

Self (Self Awareness and self development. Personal resilience, drive and

energy).

Team Player/Team Leader (Effective teamwork. Cross-team collaborations) and

Corporate Responsibility (Corporate team player. Corporate culture and

innovation).

[Insert Table 1 about here]

The aspect that appears to be missing is a model to support doctors to develop these

behaviours and thus enable them to translate the FMLM values/principles/behaviours to

their personal context of practice. As these clusters of behaviours can be mapped to

Covey’s 7 Habits® (Covey, 1989) it could be argued the Covey’s model bridges this

gap.

The key theme throughout the literature is the importance of trust demonstrated through

leaders acting with integrity and a values-based approach. This implies the need to

restore the character ethic and a model that has been developed to facilitate this, is

Covey’s (1989) 7 Habits of Highly Effective People®.

Aim

The aim of this paper is to review Covey’s principle-centred leadership model and to

explore whether the 7 Habits® can be applied to medical practice.

An overview of the 7 Habits of Highly Effective People: restoring the

character ethic® (Covey, 1989) in relation to the medical context

Covey (1989) argues we tend to focus on quick fix solutions rather than underlying root

causes; how to appear to be rather than how to be. His argument is, if you want to

change the situation, start with self. Before leaders can focus on personality ethic and

techniques, they need to ensure a strong character ethic (especially integrity) because

‘what we are communicates far more than what we say or do’ (Covey, 1989:18).

Through developing the 7 Habits®, Covey suggests people move along a maturity

continuum from dependency to independency, to the highest level of interdependency.

This links with collective including system leadership approaches (West et al, 2014).

Covey’s model is aligned with the maturity continuum so the first three habits focus on

the character ethic and the next three focus on the personality ethic, the outward

expression of self. Relating the model to the FMLM standards, the character ethic

resonates with the behaviours that can be observed, measured and developed. The final

habit 7 focuses on ‘sharpening the saw’®, self renewal, reflection and self development.

Covey (1989) argues the key to personal effectiveness is when your character and

personality ethic are aligned with your values/principles. Effective people are guided

by their own personal vision/values/beliefs/principles which provide a blue print for

decision-making and influences their actions and behaviours. This resonates with

Francis’s recommendation that the right leadership should be in place ‘to nurture the

right values and behaviours’(Francis, 2013:1399). In the healthcare context personal

goals should be aligned to both team and organisational goals/vision, so we have a

shared purpose and collective vision (Department of Health, 2013b; West et al, 2014;

Rose, 2015). Therefore time and energy should be spent on things that matter most i.e.

things that are important to the medical context – delivery of high quality patient-

centred care, patient safety, patient experience, staff engagement, effective team-work,

developing a learning values-based culture and positive climate.

Covey (1989) suggests the key to understanding the 7 Habits of Highly Effective

People® is to consider the actions an effective and ineffective person would take in

relation to each of the 7 Habits®. These habits have been translated to the medical

context (Table 2). [Insert Table 2 about here]

Innovation and application to the educational context

Covey’s 7 Habits® model (1989) has been embedded within a post graduate medical

leadership module that was commissioned by Health Education England North

West(formerly Mersey Deanery). The medical leadership module is delivered by Edge

Hill University in collaboration with the Royal College of Physicians. The 7 Habits®

model has been taught to twenty cohorts of senior medical trainees across all specialities

(423 trainees over a three year period).

The module assessment strategy requires the trainees to reflect on their leadership

qualities, skills, values and leadership approach as well as how they impact on others.

The trainees are provided with a variety of self assessment tools including a

benchmarking exercise against Covey’s 7 Habits®. Within their assignment the trainees

can choose which self assessment tools to reflect on in-depth. The trainees are also

required to apply their reflection to their context of medical practice so they gain new

insight in terms of how they impact on their team, manage their service and lead people

through the change process. There are some recurring choices in the selection of

significant self assessment tools within the submitted assignment. Four key themes have

been identified (Emotional Intelligence, Personality Type Preference, Team Role and

Covey’s 7 Habits® or individual habits and related tools). Covey’s 7 Habits® are a

popular choice with trainees in relation to understanding self and the impact of self on

their team.

As Covey’s model has been such a popular choice a bespoke self-assessment tool,

which facilitates reflection on both the 7 Habits® and the FMLM standards, has been

developed by the authors This tool makes explicit the resonance between Covey’s

model and the medical leadership standards.

In addition an applied version of Covey’s model has been developed for the medical

context (Figure 1). The foundation for the applied model is an inside-out approach with

the NHS values and principles in the centre. The applied model is based on concentric

circles to illustrate the individuals increasing spheres of influence; leadership starts with

understanding and managing self, then managing your team and finally an ability to

both manage and lead practice based change. This development is facilitated through a

values-based approach, based on integrity and having the right mindset therefore the

development of a strong character ethic is required before trusting relationships can be

developed with others. Practical tips to apply the model to the medical context are

explored in Figure 1.

[Insert Figure 1 about here]

The resonance between the solutions to the leadership challenges outlined within this

article and Covey’s 7 Habits® (1989) are illustrated in Table 3.

[Insert Table 3 about here]

Conclusion

The consensus of opinion is that leadership should be authentic, based on principles that

are aligned with the NHS values and beliefs (DH, 2013b; Francis, 2013; NHS England,

2014; West et al, 2014; Rose, 2015;) as well as medical standards (Academy of Medical

Royal Colleges and NHS Institution for Innovation and improvement, 2010; FMLM,

2015; GMC, 2016). It is also argued the cultural foundations should be based on

openness and honesty (Francis, 2013) so doctors are able to challenge practice, identify

risks and champion patient safety (West et al, 2014).

Within such a culture activists with an ability to champion change, a passion to innovate

and to energise people to work together will flourish. Fairman (2014) refers to these

people as ‘mavericks and radicals’, people who ‘lead from the edge’, think differently

and create the constructive change necessary for transformational change. They achieve

this through working within their sphere of influence and thereby expand their

connections. Effective medical leaders also require courage and resilience to challenge

standards, behaviours, actions (West et al, 2014) and to overcome Heffernan’s (2011;27)

notion of ‘wilful blindness’. This point is further supported by Halligan (2013:116) who

argues ‘what you permit, you promote’.

It is also acknowledged that we need to ‘develop a value-based culture’ and this requires

effective leadership (Rose, 2015:49). Rose (2015) further argues effective leadership

exists within an organisation when there is a shared understanding, a clear sense of

purpose, colleagues share values, trusting relationships are evident and where people are

nurtured and supported in their roles.

We suggest Covey’s 7 Habits® (1989) provides a framework to implement this vision

and provides doctors with a model to develop an authentic, appreciative values-based

leadership style. In order to apply the model to the medical context, we propose an

applied version of Covey’s model (Figure 1). We further suggest Covey’s model

facilitates benchmarking against the FMLM standards (FMLM, 2015) and thereby

supports doctors to identify their personal leadership goals, the aim being to gain insight

into how they could develop a values-based approach to medical leadership.

Key Points

Leadership is integral to a doctors’ professional role and personal effectiveness. Post Francis a values-based, authentic leadership approach is required. Covey’s 7 Habits® provides doctors with a model to develop a principle-

centred, values based leadership approach. The adapted model offers a structured, reflective and practical approach to

demonstrating leadership authenticity and trust

Conflict of interest

The authors report no declarations of interest.

Copyright

Permission has been gained from Michael Bettin, Franklin Covey Co. on 11.7.2016 and

21.9.16 to include direct quotes from Dr Stephen R. Covey’s work and the 7 Habits

Model®.

Acknowledgments

We would like to thank Dr Margaret Bamforth former Post Graduate Dean at Health

Education England (North West) for her constructive comments on our paper. We

would also like to thank Health Education England (North West) for their permission to

publish this paper and Franklin Covey Co. for their permission to include Covey’s

references and 7 Habits® Model. Finally thanks to our colleagues at the Royal College

of Physicians.

The medical leadership module referred to within the article was commissioned by

Health Education England (North West).  The module is delivered by Edge Hill

University and the Royal College of Physicians.

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Table 1. The principles underpinning the 7 Habits of Highly Effective People® (Covey, 1989) mapped to the core values and principles outlined within the Faculty of Medical Leadership & Management standards for medical professionals (2015)

The FMLM values are espoused in the seven Principles of Public Life (The Committee on Standards in Public Life, 1995) and the GMC guidance, Good Medical Practice (2013). This section needs to be linked to the table title.

Covey Principles

Fairness - equity and justice

Integrity - honesty & trust

Human dignity & compassion

Service – the idea of making a contribution

Commitment to quality orexcellence

Developing others

FMLM BehavioursSelf * * * * *

Team Player/team Leader

* * * * * *

Corporate responsibility

* * * * * *

The 7 principles of public life

Selflessness * * *

Integrity *

Objectivity *

Accountability * * *

Openness * *

Honesty *

Leadership * * * *

GMC Good Medical PracticeKnowledge, skills & performance

* *

Safety & Quality

* * *

Communication, partnership & teamwork

* * *

Work in partnership with patients

* * * *

Maintaining trust

* * *

Table 2. The 7 Habits of Highly Effective People® (Covey, 1989) applied to medical leadership standards (Faculty of Medical Leadership and Management, 2015)

Habit and linked behaviours Application to medical leadershipHabit 1 Be Proactive® - take responsibility for own actions/behaviours rather than a reactive mindset. The habit of pro-activity links to self-awareness, personal resilience, drive, energy, corporate team player, corporate culture and innovation

Effective medical leaders are : self-aware and understand their impact on

others; able to make decisions based on their values

and principles take responsibility for their choices.

This is consistent with transformational, values-based leadership and change

Habit 2 Begin with the End in Mind® - have a clear understanding of your vision and goals. The habit of personal leadership links to effective teamwork, corporate team player, corporate culture and innovation.

Effective medical leaders: start with a clear understanding of their final

destination; have an in-depth understanding of both their

real self and their ideal self their vision/goals are aligned to their

values/beliefs/principles their time and energy is focused on what is

most important.

Habit 3 Put First Things First® - ensure you spend your time and energy on what is most important rather than being driven by issues perceived to be urgent. The habit of personal management links to personal resilience, drive, energy, corporate team player.

Effective medical leaders are able to: prioritise according to what matters most i.e.

Habit 2, their vision/goals/aims/objectives adopt an authentic, self-aware, principle-centred

approach to leadership so their actions, behaviours and decisions are consistent with their values/principles.

Habit 4: Think Win-Win® – ensure you adopt a win-win approach rather than a win-lose or lose-win® mindset. The habit of win-win links to effective teamwork, cross-team collaborations, corporate culture and innovation.

Medical leaders with a Win-Win® attitude: are able to appreciate and seize opportunities

that add value to both self and others require a strong character ethic particularly trust,

respect and the development of collegial relationships.

Habit 5: Seek First to Understand, Then to Effective medical leaders:

be Understood® - based on empathic listening. The habit of personal communication links to effective teamwork, corporate culture & innovation.

actively listen with the express intention to understand the perspective of others

are able to communicate effectively with openness, honesty and transparency

require emotional intelligence, empathy, compassion, integrity and consideration of other viewpoints

develop authentic relationships based on mutual trust

Habit 6: Synergise® - the ability to explore alternative solutions through adopting a win-win mindset, rather than compromise, fight or flight. The habit of creative co-operation links effective teamwork, cross-team collaborations, corporate culture and innovation.

In order to develop alternative options, effective medical leaders;

have a strong character ethic based on integrity, trust, respect, credibility

are able to embrace diversity and have an inclusive approach

are able to appreciate and value another’s perspective (patients/carers, colleagues, managers), can be a positive opportunity for change.

Adopt a strengths-based, inclusive approach, recognising that each team member is a valuable asset with a positive contribution to make

Habit 7: Sharpen the Saw® - the ability to self-renew and top up your resilience in order to prevent burn out, stress and stagnation. The habit of self renewal links to self-awareness, personal resilience, drive, energy, corporate culture & innovation.

Effective medical leaders have: Insight and awareness of their personal

resilience levels, what re-charges their battery and strengthens their resilience and what drains their resilience levels

a high degree of emotional intelligence, able to acknowledge and act upon signs of stress.

seek out ‘critical friends’ who are able to provide both support and challenge, with honest, constructive feedback, on their attitude and behaviour, so early intervention is possible.

recognise the value of critical reflection and action planning leading to continuous personal and professional development

Table 3. Solutions to the key leadership challenges mapped to Covey’s 7 Habits Model® (1989)

Solutions to the key leadership challenges(Academy of Medical Royal Colleges and NHS Institution for Innovation and improvement, 2010; Department of Health, 2013b; Francis, 2013; Bevan and Fairman, 2014; West et al 2014; Kutsyuruba and Walker, 2015; FMLM, 2015; Rose, 2015; GMC, 2016)

Links to Covey’s (1989) 7 Habits Model®

A new leadership approach is required based on a shared purpose and collective vision.

Habits 2 and 3

A learning culture and positive climate is also required. Habits 4,5,6

The cultural foundations should be based on openness and honesty so doctors are able to challenge practice, identify risks and champion patient safety.

Strong character ethic – a principle-centred approach based on integrity.

Within such a culture activists with an ability to champion change, a passion to innovate and to energise people to work together will flourish.

Personality ethic – the outward expression of your values, principles and beliefs results in authenticity.

Leaders require an ability to challenge and take action. Habit 1

High performing teams need to be enabled to develop. Development of the habits enables leaders to move from independency to interdependency through developing trusting relationships with others.

Leaders are required to be positive role models, champion morale and behaviours and develop trusting relationships.

An inside-out approach requires a strong character based on the principles underpinning Covey’s model.

It is essential to reflect on the progress of the change, its impact and team performance.

Habit 7